Managed Care: A National Overview

NAMIís Position (summarized from the NAMI Policy Platform)

NAMI supports health care for all persons with brain disorders that is affordable, nondiscriminatory, and includes coverage for effective and appropriate treatment. NAMI supports federally mandated minimum standards for health insurance coverage. NAMI supports efforts of states to gain waivers of ERISA (Employee Retirement Income Security Act) so self-insured employer health plans would comply with state-mandated minimum benefit laws. Managed care organizations must be held accountable for delivering a comprehensive array of community support services, and appeal and grievance procedures must be in place that are user-friendly and time-sensitive.

The Need to Stand and Deliver

A crisis of confidence in health plans exists throughout the nation. National mandated legislative solutions are required to restore consumer confidence in health plans.

In September 1997 NAMI published Stand and Deliver: Action Call to A Failing Industry. The report observed that managed care plans failed to deliver on the following expectations: publicly available and current practice guidelines, easy hospital admission and flexible hospital length-of-stay, PACT programs, immediate access to all effective medications, suicide attempt viewed as a medical emergency, consumer and family participation in their treatment planning and care, measurement of clinical outcomes, access to psychiatric rehabilitation, and access to secure and supportive housing.

In an October 1998 NAMI survey of consumer and family experiences with managed care, 25 percent of respondents had positive experiences with managed care in four areas: improved access to treatment, emphasis on preventing crisis, focus on consumer satisfaction, and decreased unnecessary hospitalization.

The five areas of most negative experience with managed care were: donít know how to file an appeal (55 percent); seeing the patientís doctor (41 percent); problems getting medications (34 percent); problems getting crisis services (33 percent); and problems getting admitted to a hospital (28 percent). Twenty-five percent of respondents had filed an appeal with their health plan; families were successful 54 percent of the time and consumers were successful 42 percent of the time.

Managed Care: A National Overview

According to a July 1998 SAMHSA-Lewin study, 46 states are implementing 88 different managed behavioral healthcare programs. Only Maine, Mississippi, Nevada, and Wyoming have no public-sector managed behavioral healthcare programs. Of these 88 programs, 83 have mental health and 66 have substance abuse. Sixty-one (69 percent) include both mental health and substance abuse. However, 41 of these programs had been in operation less than one year. There is a roughly 50/50 split between at-risk programs and administrative services organization (ASO) arrangements. Fifty-five percent of the programs use behavioral healthcare carve-outs, but only 17 percent use non-Medicaid funds.

Colorado, Iowa, and the city and county of Philadelphia are generally viewed as the most positive of these initiatives but even there access problems exist.

Iowa and Massachusetts seem to be more advanced in terms of the development and use of performance-based measurements. Philadelphia leads the nation in the use of consumer satisfaction teams, teams staffed by consumers and family members to ascertain enrollee dissatisfaction.

Montana and Tennessee have reputations as having the most problematic public-sector managed behavioral health care in the nation. After 23 months of operation, the Montana Legislature terminated the program. These states share common mistakes. There was no previous managed care experience in the states, yet they quickly implemented a managed care program statewide. Historic patterns of service utilization by the Medicaid population were unknown, yet the states added non-Medicaid-eligible, uninsured populations to the managed care program and even included a pharmacy benefit, even though historic patterns of utilization were not known. Both states reduced spending, anticipating budget savings from the programís financing before any actual implementation experience occurred.

NAMIís Advocacy Strategies and Goals

NAMIís Stand and Deliver report identified nine measures of success. These measures have been updated into 10 suggested action steps:

Authentic, early, and continuing consumer and family involvement in all stages of programming. Authentic means that the involvement was not token, but actually had an impact.

Standardized benefit packages based on parity for mental illness so that consumers can compare health plans based on performance.

Public release of comparative performance by health plans and treating providers. Performance data should be explicit, benchmarked, standardized, publicly available, and independently validated.

Public release of consumer satisfaction data, complied by consumer satisfaction teams, staffed by consumers and families, external to the health plan, but with the health planís commitment to immediately respond to complaints, grievances, and dissatisfactions.

Consumer and family surveys, such as NAMIís Stand and Deliver.

Publicly available practice guidelines, which are adhered to by a health planís treating providers.

Immediate access to needed care.

Effective and timely grievances, appeals, and decisions using third-party, independent, binding clinical review. The use of independent, third party consumer and family facility and program monitoring teams and the use of independent ombudsmen programs are helpful.

Suicide attempts viewed as a medical emergency.

Standardized premium-rate structures so that consumers can compare health plans based on performance and risk-adjustment cost reimbursement so no plan is penalized because it enrolls and serves a population with more severe illness.

Other lessons learned can be action steps in advocating accountable and responsible managed care programs. These include:

Precisely define in the public domain, preferably in authorizing legislation, key terminology such as the actual benefits, how benefits are actually accessed, and medical necessity.

Consider using the Massachusetts practice where 100% of the capitation is devoted to clinical care; where pharmacy is not included in the behavioral health benefit capitation; where a separately funded, adequately funded, and separately negotiated administrative budget (currently 9% of the total expenditures) operates; and where profit is entirely tied to the achievement of performance goals. Massachusetts also uses risk corridors where potential profits and losses are capped.

Use other successful state capitation rates when examining the adequacy of your state or local capitation rate.

Implement detailed seamless systems of care between the Medicaid and public mental health systems. Even in states with more positive managed care experiences, such as Colorado and Massachusetts, the responsibility line between Medicaid and the public mental health system is not clear and people are denied or delayed access to care.

For more information about NAMIís activities on this issue, please call Clarke Ross at 703/312-7894. All media representatives, please call NAMIís communications staff at 703/516-7963.